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Community Health Program

Community Health Program - Outpatient Care Management Program

The CHP Outpatient Care Management program is dedicated to improving the health of the community, improving access to health care for the uninsured and reducing unnecessary hospitalizations.  The program works toward these objectives by developing and implementing model health programs in an effort to influence policy changes.  The CHP was started in 2007 as a pilot project to reduce potentially avoidable acute care visits while increasing access to primary care for patients with select chronic diseases.  This unique program combines care management and disease management to establish patients with a medical home, improve access to prescription medications, increase knowledge of disease and establish self-management goals.  Registered nurse care managers work with community health workers and a social worker to achieve positive results. 

Aim 1. Assess the effectiveness of an integrated care and disease management program on the utilization pattern of the UTMB ED in the uninsured, chronic disease population of Galveston County;

Aim 2. Assess effectiveness of an integrated care and disease management program on the utilization of inpatient admissions in the uninsured, chronic disease population of Galveston County;

Aim 3. Assess effectiveness of assigning patients to a medical home on primary care utilization for the uninsured chronic disease population participating in an integrated care and disease management program;

Aim 4. Assess aggregate costs associated with healthcare utilization for uninsured, chronic disease participants in an integrated care and disease management program in Galveston County. 


CHP – Social Service Block Grant (SSBG) – Houston Galveston Area Council Award for Outpatient Care Management Program

The Outpatient Care Management program was awarded over $800,000 in SSBG disaster relief funds in an effort to improve access to healthcare for those uninsured Galveston and Brazoria county residents with chronic disease who were impacted by Hurricane Ike.  This enabled the program to hire increased staff and expand services to Brazoria County.  The SSBG funded program is open to any uninsured resident of Galveston or Brazoria County without regard to previous relationship with UTMB.  The grant award is scheduled to expire on September 30, 2010.

With the aid of the SSBG funding, the outpatient care management program designed and implemented a series of workshops aimed at improving nutrition and lifestyle choices as a way of managing chronic disease.  The classes are held at local Kroger grocery stores.  Members of the CHP staff assist the participants to shop for healthy foods at the end of each presentation. Enrolled participants who attend the classes receive a Kroger gift card to purchase healthy food items.


Short-Term Care Management

The CHP has worked with both the Emergency Department staff and the staff of the ACE/Geriatric unit to pilot short-term care management in an effort to reduce readmissions in specific populations.

  • Emergency Department Short-Term Care Management – in an effort to reduce potentially avoidable ED readmissions, the CHP developed a short term, telephonic care management program. The objectives of this program are to reduce return visits for the same condition in the uninsured population by:
    • Contacting patients to make sure they were able to obtain prescribed medications
    • Patients have a follow up or primary care provider visit scheduled
  • Short -Term Care Management for Medicare CHF Patients – The CHP was approached by the ACE/Geriatrics unit staff to assist them in reducing the rate of readmissions in their Medicare funded CHF (congestive heart failure) patients.  In July, 2010, a 30 day program was designed and implemented that addresses:
    • Medication reconciliation
    • Physician follow up visit with a certain number of days
    • Patient education regarding signs and symptoms of worsening condition to be reported to their physician
    • Patient education regarding self-management of their condition


Community Health Workers (CHW)

In 2009, the CHP began working with Coastal and East Texas AHEC to introduce Community Health Workers into the CHP.  Coastal AHEC provided the training and certification program for CHWs and as of June 2010, CHP has three certified CHWs on staff.  The CHWs work in teams with the RN care managers to provide lay person level education regarding:

  • Disease state self management
  • Community resources
  • Patient navigation
  • Assistance in obtaining medications

Historically, CHWs have not been paid providers but instead have worked in volunteer roles.  As an employer of CHWs, UTMB and the CHP have become active in the current movement to recognize CHWs as a reimbursable job code by the State of Texas.  We have joined the CHW Workforce Committee, a subgroup of the Texas Public Health Association and are active in promoting this new level of care in the community.


President’s Cabinet Award Grant

The CHP has been awarded a grant from the 2010 UTMB President’s Cabinet Award program to conduct nutrition workshops specifically aimed at diabetics.  The grant proceeds will be utilized to conduct nutrition workshops for all of the CHP enrollees with a diagnosis of diabetes.  The goal of the workshops will be to improve overall diabetes management as well as lab values associated with diabetes.


Synergy  Participation

The CHP will be participating in the Family Home Visit program for the second year in school year 2011.  The Family Home Visit program brings together first year students from the medical school as well as the school of health professions and the school of nursing to give the students their first experience with community based care and patient interviewing.  The CHP is a site choice for students to gain access to a family to develop their patient interviewing skills.  Additionally, students will learn about the CHP, care management/patient navigation and community based care. 


Community Collaborations

Collaborations with St. Vincent’s Nurse Managed Health Clinic and Galveston County Health District - 4C’s clinics as one of the primary goals of the CHP is to establish patients with a medical home, collaborations with community clinics whose mission it is to care for uninsured individuals, is of utmost importance.  Good relationships have been established to successfully coordinate and manage care for the patients that are shared between the clinics and the CHP.



Hospital Charitable Service Awards - Nominee

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Phone: 409.747.2789 • Fax: 409.747.2795 • HPLA.mail@utmb.edu
Office of Health Policy and Legislative Affairs, Galveston, TX 77555-0916